Quality of Regional Nodal Irradiation Plans in Breast Cancer Patients Across a Large Network—Can We Translate Results From Randomized Trials Into the Clinic? |
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| Authors: | Diane C Ling Bryanna L Moppins Colin E Champ Vikram C Gorantla Sushil Beriwal |
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| Institution: | 1. Department of Radiation Oncology, Magee-Women’s Hospital, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania;2. Augusta University/University of Georgia Medical Partnership, Athens, Georgia;3. Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina;4. Division of Hematology/Oncology, Magee-Women’s Hospital, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania;1. Department of Radiation Oncology, City of Hope Medical Center, Duarte, California;2. Department of Radiation Oncology, University of California San Diego, San Diego, California;3. Department of Radiation Oncology, Arizona Oncology, Tucson, Arizona;4. Department of Radiation Oncology, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania;1. Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina;2. School of Information and Library Sciences, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina;3. Carolina Health Informatics Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina;1. Department of Radiation Oncology, City of Hope National Medical Center, Duarte, California;2. Department of Biostatistics, City of Hope National Medical Center, Duarte, California;1. Department of Oncology, University of Torino, Torino, Italy;2. Medical Physics Unit, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza, Torino, Italy;1. Department of Radiation Oncology, Cross Cancer Institute, Edmonton, Canada;2. Department of Oncology, Cross Cancer Institute, Edmonton, Canada;3. Department of Oncology, University of Calgary, Calgary, Alberta, Canada |
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| Abstract: | PurposeRegional nodal irradiation (RNI) improved disease-free survival by 3% to 5% in 2 large randomized trials, but this small absolute advantage relies on accurate contouring and dose delivery. We audited our network to determine compliance on regional nodal coverage, contouring, and dosimetric parameters with respect to accepted guidelines.Methods and MaterialsIn our network, we have established a clinical pathway for patients with node-positive breast cancer that guides indications for RNI and dosimetric goals. We reviewed records of 183 patients with nodal macrometastases after upfront surgery or involved nodes of any size after neoadjuvant chemotherapy. Radiation treatment plans were examined to determine lymph node volumes treated, whether nodes were contoured, quality of nodal contours, and whether target coverage and normal organ dosimetric constraints were met when RNI was delivered.ResultsDespite the presence of macrometastases on sentinel lymph node biopsy, no lymph nodes were treated in 2.2% (4 of 183). Of 179 patients who received nodal irradiation, 18 received radiation to axillary levels 1 and 2 only, and 161 patients received RNI. Overall, regional nodes were not treated despite strong indications in 7.6% (14 of 183). Treated nodes were not contoured for 2.2% (4 of 179), and lymph node contours were unacceptable in 15.4% (27 of 175). Of patients receiving RNI, 14.9% (24 of 161) did not have adequate nodal target volume coverage, mean heart dose was >4 Gy for 3.1% (5 of 161), and lung V20 Gy was >35% for 8.7% (14 of 161).ConclusionsAdherence to indications for regional nodal treatment was high, but nodes were either not contoured or had unacceptable contour quality in 18% of plans, and coverage was inadequate in 15%. Because the small disease-free survival advantage seen in trials may be decreased with these deviations, routine clinical practice requires detailed peer review to fully translate results of clinical trials. |
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